Tom Quade, MA, MPH, CPH, Interim Director of Health with the City of Akron, Ohio

I have been with the Akron Health Department in a variety of roles for more than 10 years. I have been serving as the Public Health Deputy for Administration since January of 2008 and additionally as the Interim Director of Health since April of 2009. For much of that time I have been facilitating the consolidation of the Akron City Health District with the Summit County General Health District. This endeavor has tested everything I thought I understood about leadership and management. We have not yet completed the process, but an end is in sight. It is my hope that this article will assist health department administrators considering the consolidation process. Because concisely describing the complete process, including its challenges, surprises, and learning opportunities, and to do so in a manner that can be generalized across drastically diverse contexts, is not possible in this limited space, I will draw on an analogy and metaphors that I hope will guide the reader and, I suspect, render the narrative more memorable in the end.

My wife and I recently joined four friends to go whitewater rafting, a first for each of us. I paid close attention to the instructor as we sat on solid ground prior to our launch. I rehearsed scenarios in my mind, though I still don't know how "watching for the hydraulics" helps me to navigate them. This hypothetical preparation was about as helpful as my reading the NALBOH "A Guide for Local Boards of Health Considering the Feasibility of a Consolidation of Independent Local Public Health Jurisdictions" has been in dealing with the idiosyncratic exigencies of local health district consolidation politics. The metaphor: Like navigating whitewater, consolidating health districts will include a few common elements for which one may and should prepare but in the end it is simply not something you can read in a report, or newsletter article, but please don’t stop now.

As we entered the river, we arranged ourselves such that we would create a balance of body weight. What we learned early on was that the balance we should have targeted was one of strength when the paddles hit the water and confidence when the raft was headed for the rocks. The metaphor: Like our attempt to balance our boat for the trip, our original assessment of assets, strengths and weaknesses needed adjusting on the fly. People and events will surprise you, in both beneficial and disappointing ways. The river will keep moving often with a pace you would not choose should you have the option, and you will need to adjust.
 
In selecting seats, one of my friends asserted his intent to steer by sitting in the back of the raft. Though typically one to accept and enjoy the responsibility that comes with control, I then willingly accepted the spot in the front of the boat. I have served on enough committees to recognize when the chair has been established and that there are many other seats at the table. I soon recognized two advantages of my default position. Sitting up front, I saw what was coming and that put me in the position to direct the boat simply by informing my friend who was steering the boat. Secondly, on several occasions our boat spun around, and I found myself in the steering position simply by turning myself around. I was the only one who turned around so my new crew was oriented backward, or so it was from my perspective. Oh captain, my captain. The metaphor: Like our position in the raft changed by chance and the resulting relationship between control and influence was not as anticipated, the roles one takes during the consolidation process alternate between positions of presumed control where we have far less influence than planned to the converse, i.e. a supporting role where we serendipitously may have far greater influence.

As the day wore on, our confidence grew and our fears subsided. We were completing the last run of rapids and had our eyes focused on the point where we would pull out. All of us were injury free and no one had fallen out. We turned toward shore, suddenly hit a rock, and out fell my friend's wife. Stuck between the raft and the rock, she was in no immediate danger because the current was not strong and she sustained no injury beyond her pride. Given her inability to assist her re-entry as we drifted beyond the exit point, the circumstances called for an act of desperation. The “supersonic wedgie” was employed with great success. The metaphor: Reader’s choice.

We finally exited the river, reveling in our collective success. Then we heard the news. We had to carry the raft up a very large and very steep hill to get to the bus that would drive us back up river. The metaphor: Like our realization that the real work was just starting when convinced the real work was just over, the process of consolidating health districts has presented many milestones, each worth some celebration, but in the end there is always more work to do. There will always be another step to take, another rock just under the surface that will have to be dealt with. When the MOU is signed bringing all parties in alignment, enjoy it but know that a contract may be exponentially more difficult to construct and the support you experience one week may disappear the next. There are unions to engage, vendor contracts to renegotiate, properties to manage, and budgets to reconcile. There are changing payrolls and benefits packages. And in the end you are at the beginning, the beginning of a new day with a new public health entity and a new sense of our capacity to improve the access and the quality of the public health services we provide. One thing did not change. The community we serve was there when we started and is will be there when we get done. The day after we ran the rapids, we hiked up a trail to a railroad bridge some one hundred feet over that same river and I looked down with a sense of reflective accomplishment. I hope I can have a similar bird's eye view at some point after the consolidation is done, and I hope I will feel as good as I did that day.